Growing together: The importance of the therapeutic relationship in stuttering therapy – Hilda Sønsterud and Kirsten Howells

About the Authors:

Hilda Sønsterud is a speech and language therapist in Oslo, Norway. She works in Statped’s department for speech and language disorders in Norway, and is a PhD-fellow at the University of Oslo. Hilda works primarily with treatment and clinical research related to stuttering and cluttering, and runs courses within the field of fluency disorders. Her PhD project involves a collaboration between the Norwegian Association for stuttering and cluttering, Statped, the University of Oslo, and the University of Reading. The project is a clinical treatment study, focusing on individualized therapy for adults who stutter.
Kirsten Howells is a speech and language therapist in the UK. Within her private practice, she specialises in working with children and adults who stutter, along with their families, teachers and employers.

Introduction

This article describes a recent research project examining the importance of the therapeutic relationship within stuttering therapy. The findings highlight the value of open discussion regarding the goals of therapy and the tasks or activities incorporated within that therapy. Speaking out through open discussion can lead to therapeutic growth and change.

The working alliance

It is likely that the relationship between persons who stutter and SLPs affects the course of therapy and its outcomes. The relationship matters. This importance is acknowledged within wider communities of people who stutter, such as the podcast and online community StutterTalk© which published a statement as follows, “… As the therapeutic relationship is built upon trust and understanding, let yourself ‘shop around’. If you don’t feel comfortable with the first therapist you meet, visit with another” (http://stuttertalk.com/stuttertalk-position-statement-on-self-help-and-speech-therapy-for-people-who-stutter/).

But what is it that makes this relationship between a person seeking support and a therapist successful or unsuccessful? It was Bordin (1979) who first named the relationship the ‘working alliance’. The concept can be described as the degree to which the person and the therapist are engaged in collaborative, purposive work. Flückiger and colleagues describe how ‘The alliance represents a proactive collaboration of clients and therapists across sessions and in moment-to-moment interactions’ (Flückiger, Del Re, Wampold, & Horvath, 2018, p. 330). It has been suggested that the working alliance has its foundation in three processes, described as the bond, the goal and the task. That is the emotional bond between the person and the therapist, the extent to which the person and the therapist agree on the goals of treatment, and the extent to which the person regards the treatment tasks as relevant for that goal (Bordin, 1979; Hatcher & Gillaspy, 2006; Horvath, Del Re, Fluckiger, & Symonds, 2011). Indeed, research within speech-language therapy has demonstrated that an individual’s opinion of treatment as effective or ineffective is influenced by their experience of the collaborative process in clinic (Manning, 2010; Plexico, Manning, & Dilollo, 2005, 2010).

However, although there is already consensus that SLPs should openly and honestly discuss an individual’s goals and expectations for therapy in general, there has been little previous investigation of the impact of personal motivations and the working alliance for people who stutter. Fortunately, over recent years, there has been increasing interest in the therapeutic relationship as an evidence-based component of interventions in speech and language therapy and recent research by our group (Sønsterud et al., 2019) explored this specifically within therapy for stuttering. Our findings suggested that this relationship, the working alliance that grows from describing, discussing and agreeing goals and tasks, is a critical element in successful stuttering therapy.

Based on this research, it is recommended that evaluation of the working alliance, particularly from the perspective of the individual seeking support, is incorporated into stuttering therapy.

What does this mean for people seeking therapy?

Our research highlights the importance of defining and describing your goals and preferences if seeking therapy. It suggests that how you feel about your therapist and the content of your therapy really matters. It is important for you and your therapist to understand your goals, so that you can identify appropriate approaches or activities. If something does not feel ‘right’ or relevant for you, speak out.

What does this mean for SLPs?

Our research highlights the importance of open discussion around not only the person’s goals for therapy, but also the tasks or activities to be incorporated in that therapy. It further suggests that incorporating evaluations of the working alliance at an early stage in the therapeutic process may help ensure that relevant goals have been identified and agreed and that meaningful tasks are in place. Such evaluations can also help therapists and persons who stutter to more easily identify, acknowledge and repair challenges should they arise. Tools for evaluating the working alliance are available. One such example is the Working Alliance Inventory – Short Revised version (WAI-SR) (Hatcher & Gillaspy, 2006). This tool was used in the Sønsterud et al. (2019) study referred to above. It is quick and easy to use, and explores the working alliance across the three domains of bond, goal and task.

If you would like to find out more, the WAI-SR is available online and the Sønsterud, Kirmess, Howells, Ward, Billaud Feragen & Halvorsen (2019) paper is available on this link.  We believe more research is required to further investigate the role of shared understanding of therapy goals, agreement of relevant therapy tasks, and a respectful and trustful bond in stuttering therapy.

References

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16(3), 252-260.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The Alliance in Adult Psychotherapy: A Meta-Analytic Synthesis. Psychotherapy, 55(4), 316-340. doi:10.1037/pst0000172

Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the Working Alliance Inventory. Psychotherapy Research, 16(1), 12-25. doi:10.1080/10503300500352500

Horvath, A., Del Re, A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-16. doi:10.1037/a0022186

Manning, W. H. (2010). Evidence of clinically significant change: the therapeutic alliance and the possibilities of outcomes-informed care. Seminar Speech and Language, 31(4), 207-216. doi:10.1055/s-0030-1265754

Plexico, L., Manning, W. H., & Dilollo, A. (2005). A phenomenological understanding of successful stuttering management. Journal of Fluency Disorders, 30(1), 1-22. doi:10.1016/j.jfludis.2004.12.001

Plexico, L., Manning, W. H., & Dilollo, A. (2010). Client perceptions of effective and ineffective therapeutic alliances during treatment for stuttering. Journal of Fluency Disorders, 35(4), 333-354. doi:10.1016/j.jfludis.2010.07.001

Sønsterud, H., Kirmess, M., Howells, K., Ward, D., Feragen, K. B., & Halvorsen, M. S. (2019). The working alliance in stuttering treatment: A neglected variable? . International journal of language & communication disorders, 54(4), 606-619. doi:https://onlinelibrary.wiley.com/doi/10.1111/1460-6984.12465

239 total views, 29 views today


Comments

Growing together: The importance of the therapeutic relationship in stuttering therapy – Hilda Sønsterud and Kirsten Howells — 31 Comments

  1. This was a great read. I couldn’t agree more, it’s VERY important for the client and clinician to connect on an emotional level. Without that, the client doesn’t put as much trust in the clinician, and therefore the therapy isn’t as effective as it could be. Thanks for writing this!

    • Dear Ariel!
      Wonderful to hear from you! We really appreciate your willingness to link our article to your blog. We appreciate your comment about the working alliance and the importance of being connected on an emotional level. Your blog looks great, and we think more people should follow your way of living – by being yourself!

  2. Hi Hilda and Kirsten

    Thanks so much for this paper, and for sharing your research. I am encouraged to see more and more SLPs promoting the “working alliance in stuttering treatment”, and I am sure that your influence will benefit both the SLPs and PWS.

    I am encouraged, too, to read about the alliance combining technical aspects, such as treatment goals, and emotional aspects, such as the nature of the relationship between the therapist and the client. It seems that you are guiding us to a place where counseling is part and parcel of the treatment, and this, to me, is so very important.

    Thank you.
    Hanan

    • Hi Hanan,

      Thank you so much for your thoughts and kind comments. The results of this project were very interesting and I found it fascinating to consider the practical elements that contribute to that emotional bond between two people working together.

      We do really hope that these findings will encourage PWS and SLPs to be able to look at their working relationship and regard it as a key component in any therapeutic process.

      Many thanks once again,
      Kirsten

  3. Hello Hilda and Kirsten,

    I am so pleased to see your paper on the therapeutic alliance in this year’s conference. Over the years, as a PWS, school SLP and consultant to school SLPs in stuttering, I have come to regard relationship as the central principle of stuttering therapy, around which all other principles orbit. I am thinking of what Kristin Chmela says about relationship: Helping a child who stutters starts with a conversation; that conversation shows interest in what the child is interested in, and it creates relationship. A positive relationships fosters the motivation required for a child with persistent stuttering to choose to continue to evolve as a communicator. As you write, “relationship matters”! Best,

    Rob Dellinger

    • Hi Rob.

      Thank you so much for your interest in our article and for your comments. Our research focused on adults, but it would be of enormous interest to understand which elements contribute to the forging of the working alliance between children who stammer and SLPs. As you and Kristin say, the relationship develops through genuine conversation, and it would be of enormous value to understand more about what makes some therapeutic relationships more successful than others.

      Many thanks once again,
      Kirsten

  4. Hello Hilda and Kirsten,

    Thank you so much for sharing this article. I am a graduate student currently enrolled in a Stuttering evaluation and therapy course! After my group mates and I read and discussed your paper, we wondered how often you would suggest incorporating/administering the WAI-SR to assess the working alliance?

    Best,
    Cayla, Jayna, and Blair

    • Dear Cayla, Jayna and Blair,

      Thank you so much for your interest in our article. We’re so glad that it has stimulated discussion amongst you and your group mates!

      Our study followed a strict schedule of meetings between the SLP and the PWS seeking therapy, which included an initial meeting, followed by four treatment sessions, and a subsequent follow-up. This protocol is unlikely to reflect real-life clinical situations within many environments. However, within our research protocol, the WAI-SR was administered at the second and fourth treatment sessions, and at the one-month follow-up. When used in real-life clinical situations, it is likely that incorporating the WAI-SR fairly early in therapy is likely to optimise the opportunity for the SLP and the person seeking therapy to actively use and discuss the findings, amending their collaborative therapy approach accordingly. This is reflected in our use of it at the second treatment session (which was the third time the SLP and PWS had met). A generally useful guideline might be early in the therapy process, when therapy is underway, but not so far along that it is difficult to change course.

      I hope my musings are useful!

      With warmest wishes,
      Kirsten

  5. I enjoyed reading this article and appreciate the emphasis on the working alliance. I like how it encompasses the three important components that can influence a client’s performance in therapy. It’s not a term I hear very often but it allowed me to reflect on how I’ve been addressing these topics with my clients. I look forward to using the WAI-SR in the future and incorporating it in stuttering therapy specifically. I frequently have discussions regarding goals and tasks but not much about the “bond” aspect. Considering the importance of the bond between the client and therapist in stuttering therapy, how would you suggest addressing negative ratings/responses to “bond” questions?

    Thank you,
    Gabriela

    • Dear Gabriela!
      Thank you som much for your interest, and for sharing some of your reflections about the working alliance. I am happy to hear that you consider to include the WAI-SR instrument in your clinical work in the future. I will continue doing the same. If we choose to include this form, I assume that it is easier and more natural to include aspects related to the process bond in our conversations with PWS. According to Wampold, the bond is the basis of the collaborative relationship, and needs to be created initially in the therapy process. If we as clinicians dare to discuss more openly the quality of the dyad, we might better be able to identify and agree upon goals and meaningful tasks as well -which again might contribute positively to the therapy outcome. Therefore, I would address the ratings to bond questions seriously too, in particular the items about respect and care. I have received two comments from PWS throughout the last four years related to the bond items (‘likes me’ and ‘appreciate me’) that they considered these aspects not so important. One person mentioned that the aspect of ‘liking me’ is not so important in professional relationships as it is in private relationships. Anyhow, by including it in your work, you, together with your PWS, will experience yourselves how the form works for you.
      All the best wishes, and thank you again from
      Hilda

  6. Hilda & Kirsten,

    Thank you so much for sharing this highlight and a link to the full paper. I agree, the therapeutic alliance is an integral part of the therapeutic process.

    This topic of a “therapy alliance” was first introduced to me in the Plexico, Manning, & Dilollo 2010 paper. Thank you for further discussing and clarifying points from both the client and clinician’s perspective.

    I recognize that the alliance is important, and working together with the client on both goals and therapy approaches. How would you recommend building that alliance when the only goal the client wants is complete fluency and doesn’t see value in overcoming self-stigma, etc?

    Thank you,
    Erma Hanson

    • Dear Erma!
      Thank you for your feedback and for showing interest in the topic!

      You add a very important question which is very relevant, and which is a quite common topic in stuttering therapy. I am sorry that my answer below will be just a small piece of an answer.

      Regardless of the content in the goal-led therapy, I think that we as clinicians should consider all goals from PWS very seriously/carefully and with genuine respect. I do assume that we as clinicians experience individual therapy goals expressed like for example ‘I want to get rid of the stuttering’ or ‘I want to be complete fluent’ from time to time. In these contexts we do have to listen just as carefully as usual. In such cases, I as the SLP can probe further by asking for example what would happen or what would be different for them if they achieved this specific goal. If we are wondering why being fluent matters to them, we usually receive further important information about reasons which are understandable about why the person is expressing such goals. Often there are issues which might be related to coping in life in more general. Maybe the specific reason is to read bedtime stories for their children, starting a meaningful education/job which demands increased control in speech, or being more active in social situations etc.. Then the initial goals could be regarded as process goals, and the additional information more could be regarded as outcome goals. When I do reflect together with the person about these issues, I do experience that something might change already early in the collaborative process. Often I recognize that the goals might change throughout a few therapy sessions. Some might find the goals of for example making speech or communication less effortful or increasing the sense of control in life as good alternative goals. Then the persons might more easily accept that they stutter, and they also become more open and curious about their own stuttering. Then the working alliance might be even stronger -at least when the person experiences that he/she doesn’t need to struggle that much.

      Furthermore and in general, I am careful about telling that a goal is totally unrealistic, because I don’t know this for sure. Of course, I can inform the person about that achieving total fluency is more seldom, especially when adults with chronic stuttering are concerned, but in the same time I do not want to take away someone’s hope. Usually people are much more motivated and function more effectively when the activities/tasks are aligned with goals that the person hope to reach.

      Well, I do hope that these lines make sense for you.

      Thank you again, and best wishes from
      Hilda

  7. Hilda and Kirsten-

    As a graduate student in speech-language pathology, my relationships with the people I am working with are so important, but it can be hard to effectively analyze that relationship and what exactly is leading to it being successful or not. I appreciate your link to the WAI-SR. I will be incorporating this into my toolbox for future practice.

    The therapeutic alliance integral to a successful outcome. How do you address it when the client and therapist do not have the same goals in mind and are not on the same page? Are there ways to strengthen that alliance or are there times when it is best to end the therapeutic relationship?

    Thank you,
    Megan Izzo

    • Dear Megan Izzo!

      Thank you for your interest in our article, and for sharing a common challenge upon what to do when there are lack of joint therapy goals!

      Goal-directed therapy usually requires a high level of clinical competence and also integrating therapy procedures very flexible. If you and your client are ‘not on the same page’ or you have different goals in mind, I think it might be important to share this information as early as possible. Anyhow, I would listen very carefully to the client before I am disclosing my own clinical goals, especially if or when they are not mirroring the wishes or goals of the person.

      I have been sharing a response to Erma Hanson just recently (please see above). I assume that this feedback might fit quite well with your clinical concerns. Of course I do think that there sometimes might be a discrepancy between desired and realistic outcomes. Anyhow, I assume that if you and your client does not find a common collaborative ‘page’ after an honest and good talk or after a few sessions, it might be very hard (for both of you) to continue the collaborative work. In the same time, authentic and honest shared reflections from both the perspectives usually increase the quality of the working alliance. I therefore sometimes invite the person to agree upon some goals by breaking them down into sub-goals or tasks. Usually it is easier to find a joint platform or ‘page’ for further collaboration then.

      Thank you again for your feedback and important question. I wish you the best for your important work within the stuttering (and cluttering?) field in the future!

      Best wishes,
      Hilda

  8. Good Morning Hilda and Kirsten,

    I want to extend my thanks for having such a concise, informative paper regarding the importance of a therapeutic alliance. Personally, I believe a therapeutic alliance can apply to all clients, not just clients who stutter. I enjoyed that there is so much research to support the importance of therapeutic alliances between the clinician and a client who stutters. Using evidence-based practice is such a crucial thing for clinicians to be able to provide the best possible services. I appreciated all the additional resources I was not yet exposed to. I had never heard of the WAI-SR and providing the link made it easy for me to save for later application.

    Additionally, I had never heard of the identification of the bond, the task, and the goal. I really like the idea that those 3 variables are vital in being a successful clinician. I particularly wonder about “the task” because psuedostuttering can have such a vital impact that it is an important task that should be implemented. However, I worry that clients may be against that task because of the uncomfortableness that it will bring. If a client refuses to participate in that particular task, would you continue to ask your client if they are ready for that task yet as therapy progresses or just accept their decision and not bring it up again?

    Thank you!
    Mackenzie McBride

  9. Hilda and Kirsten,

    Thank you for all the information, I appreciate that you addressed both sides of the relationship. I have been learning about the therapeutic alliance and understand how it needs to be foundational for any therapy. Although I appreciate the importance of working together on goals and therapy activities, as a professional, what do you do if someone says the only goal they have is to fix their stutter? Knowing that fluency techniques can be used but won’t fix it, what would you do to bridge the gap between their goal and what you know is a realistic goal?

    Thank you,
    Jessica

  10. Hilda and Kirsten,
    As an SLP Graduate student with a client who stutters, I am very interested in this topic. A lot of our text books and other readings have emphasized the importance of the client clinician alliance. Because I only have a few weeks to work with my client, I feel this emphasis, especially. As I endeavor to build this relationship I will be adding in aspects of client evaluation to our sessions in order to help ensure as collaborative an experience as possible.
    Thank you for presenting this.
    Regards,
    Tabitha Syme

  11. Hilda and Kirsten,

    Thank you for sharing this article on working alliance. As a Speech Language Pathologist graduate student, this is a great topic to discuss and learn more about. While working with our clients, it is important to create a relationship in order to allow a safe and open discussion and allow for growth. I found this article educational by learning the importance of an alliance with our client’s as well as their parents. Parents may also feel alone in this situation and it is important to provide community support groups for them too. We tend to focus on our client’s needs and might forget about informing services for the parents.

    Thank you,
    Rebecca

  12. Hello Hilda and Kirsten,

    Thank you for sharing your insight. As a future SLP, I hope to always try my hardest to make future clients feel secure, safe, and able to express themselves in my presence. I was wondering, while given all the perfect circumstances, a good/safe environment for conducting therapy, and excellent client-patient relationship, etc., do you think it is possible to see little to no success in this particular subject? Would the younger children be more susceptible to seeing quicker results since they are still molding their language versus adults?

    Thanks,
    Casey

  13. Hi Hilda and Kirsten,

    I am a current graduate SLP student and doing my externship at a middle school. I am working with a student who stutters at the moment and have administer the SSI-4. You mentioned that there are tools to evaluate the relationship between the therapist and student. My question is: would you recommend this evaluation to be provided after rapport has been built, or only when a problem arises with the client? Also, this student has a tendency of not attending class and sometimes missing therapy sessions due to this (she is not in scheduled class when we go pick her up). Therefore, there is a lot of counseling going on during our sessions (when we do meet). Do you recommend the Working Alliance Inventory – Short Revised version (WAI-SR) (Hatcher & Gillaspy, 2006) to be administered with this client?

  14. Hi Hilda and Kirsten,
    Thank you for your research and explanations of a strong working alliance between a speech pathologist and an individual who stutters. I liked how it was explained simply by evaluating the bond between the clinician and the client, agreement on the goals of therapy, and the tasks to reach that goal. As a speech pathologist graduate student, I feel that it would be a quick helpful task to regularly check in on bond, goal, and task with the client to be sure you are in agreement and moving in a positive direction throughout treatment. The WAI-SR is also a helpful resource; thank you! I also appreciated how you mentioned that individuals seeking treatment should shop around. We all have different personalities and styles, and in something as vulnerable as stuttering therapy, a right fit is important. I also appreciated your advice to individuals to “speak out” if there are any questions about treatment tasks or goals, as the open communication is imperative for building a positive relationship. Thank you for your presentation!
    Nicole

  15. Hello Hilda and Kirsten,
    I enjoyed your discussion of the importance of therapeutic alliance. I like the idea of having an evaluation tool to facilitate the ongoing discussion between the clinician and client about their rapport. I thought it was interesting that you pointed out that both therapeutic goals and treatment activities should be agreed upon by both the clinician and the client. The idea of ensuring that all treatment activities need to be something that the client agrees is appropriate made me wonder if that ever leads to a situation in which the client fails to make as efficient progress because they aren’t willing to agree to treatment tasks that are uncomfortable or overly difficult at first. Is that something you have found occurs in this model? How would you recommend a clinician work to avoid this type of problem?
    Thank you,
    Sarah Aldrich

  16. Hello,

    I really liked your explanation of therapeutic alliance as the bond, the goal, and the task. I think this provides a functional framework for self-evaluation for clinicians who service persons who stutter. I am a graduate student studying speech-language pathology and today I had this exact conversation with my clinical supervisor. We were discussing the importance of incorporating parents goals and understanding their beliefs about therapy for their child. She further explained that when a parent does not feel heard or received by the clinician it can often create that situation in which the parents feel the need to shop around for a new clinician. And while there are times that it is important to shop around for a knowledgeable and fitting clinician, I think as clinicians its important for us to asses how we are assisting this process. Are we balancing our clinical expertise and treatment ideas with the thoughts of the client to provide successful outcomes for that particular individual. Thank you for your paper.

  17. Hello,
    As a future SLP, I understand the importance of a strong working alliance. I have a few questions over the process of the WAU-SR. After your initial evaluation with a patient, you agree you have a strong working alliance and start therapy. If you were to run another WAU-SR evaluation later into the patient’s therapy, and you and the patient find the work alliance no longer lines up what steps would you take from there? Recommend a new therapist? Re-evaluate the goals of treatment? And how often do you need to evaluate the work alliance?
    -Alexis

  18. Hilda and Kirsten,
    Thank you for speaking about this important topic. I think that the therapeutic alliance is really interesting because as a student clinician the emphasis for most supervisors and professors is the validity of the treatment and not the client-clinician relationship. I also am aware of some of the barriers we have a clinicians because we are not counselors. We can listen and support, but what if there are issues we aren’t prepared to deal with? How do you know your boundaries as a clinician? Do you ever collaborate with a counselor to make sure your client is being supported in the best way possible?

    Thank you,
    Amanda T

Leave a Reply